Complex Medical Management Solutions

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Online Referral Form

Client Information

CLIENT:		DATE:	11/25/2024
Address:		Claims Handler:
City:		Phone:
State:		Fax:
Zip:		E-Mail:
Claim No.:		Coverage:	WC Auto Liability
			Disability Other

Insured Information

INSURED:
Address:		Contact:
City:		Phone:
State:		Fax:
Zip:

Claimant Information

CLAIMANT:		Occupation:
Address:		DOB:
City:		DOI:
State:		Fax:
Zip:
Phone:		Injuries:

Additional Information

TREATING PHYSICIAN:		ATTORNEY:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
Phone:		Phone:
Fax:		Fax:

Service Requested

Medical Case Mgt.
Catastrophic Case Mgt.
Qualified Rehabilitation Consultant
Long Range Cost Projections

Vocational Case Mgt.
Limited Assigment

Telephonic Case Mgt.
Medical/Legal
Disability Case Mgt.
Consultative Services

Report Preferences

	Additional Instructions
E-Mail Fax Standard mail

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